Alcohol Intoxication

HISTORY:

Alcohol intoxication

Alcohol intake: ‍ ‍beerwinespirit drinks in the past ‍ ‍hoursdays

Typical pattern of consumption: ‍social drinkingbinge drinkingdaily useheavy drinking

Behavioral changes noted by: ‍selffamilyfriendslaw enforcement

Attempts to reduce or stop alcohol consumption: ‍yesno

Presence of tolerance: ‍yesno

Withdrawal symptoms when not drinking: ‍yesno

‍slurred speech

‍incoordination

‍unsteady gait

‍impaired attention

‍decreased level of consciousness

‍aggressiveness

‍mood lability

‍impaired judgment

‍nausea

‍vomiting

‍depressed mood

‍suicidal ideation

‍homicidal ideation



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Alcohol intoxication ‍confirmedlikelysuspected

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍glucose, ‍LFTs, ‍INR, ‍ethanol level

- Urine toxicology screen

- ECG

- Monitor vital signs

- ‍IV fluids

- ‍Thiamine

- ‍Anti-emetics

- ‍Sedatives for agitation

- ‍Multivitamin

- Observation until sober

- Referral to addiction services

- Referral to social worker

- Referral to psychologist

- Safe transport home

- Admission if no safe discharge plan

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as confusion, seizures, or persistent vomiting